Sugar Substitutes and Health: A Review

Review Article Sugar Substitutes and Health: A Review Vipin Kumar Sharma 1, Navin Anand Ingle 1, Navpreet Kaur 1, Pramod Yadav 1, Ekta Ingle 2, Zohara Charania 3 1 Department of Public Health Dentistry, K.D. Dental College and Hospital, Mathura, Uttar Pradesh, India, 2 Department of Oral Medicine and Radiology, Vasantdada Patil Dental College, Sangli, Maharashtra, India, 3 Department of Public Health Dentistry, Guardian Dental College, Amarnath, Mumbai, Maharashtra, India ABSTRACT Artificial sweeteners also referred to as sugar substitutes or low-calorie sweeteners are non-nutritive, high-intensity sweeteners. Artificial sweeteners may be in so many foods, drinks, drugs, and hygiene products that some argue that every citizen of Western countries probably uses them. Because they are so sweet, less is needed to sweeten foods and fewer calories are added. The availability of a variety of safe sugar substitutes is of benefit to consumers because it enables food manufacturers to formulate a variety of goodtasting sweet foods and beverages that are safe for the teeth and general health. Keywords: Artificial-sweeteners, aspartame, sugar substitutes, sucrose, xylitol INTRODUCTION The process of dental caries is one of the oldest and ubiquitous diseases of the prehistoric and modern times. Hundreds of dental research investigators like Miller, Gottleib, Keye for more than a century have studied various aspects of dental caries etiopathogenesis. [1] Dental caries is still a major problem across the world affecting 60-90% of school children and adults (WHO 2003). The Indian scenario is no better with a caries prevalence rate of 83.4% amongst the 15 years old group, while 83-86% in 35-44 years old population. [1] According to the currently accepted concept caries is truly a multifactorial disease. Interaction between three primary factors namely host tissue-the tooth, microflora with cariogenic potential and suitable local substrate, i.e., diet; is essential for initiation of caries disease process Keye (1960). However, Newbrun Quick Response Code: Access this article online Website: www.joaor.org DOI: 10.2047/joaor-07-02-007 (1982) added a fourth factor time to the three above factors and the concept came to be known as caries tetralogy. [1] It is difficult to avoid sugar in diet but reducing the amount and exposure to sugar in diet of humans especially children is an important consideration in preventing caries thus non-cariogenic sweeteners offer good alternative to sugar if used in moderation. These sugar substitutes do not promote caries. [2] A sugar substitute is a food additive that duplicates the effect of sugar in taste, but usually has less food energy. Sugar substitutes are natural, as well as artificial and very much popular these days because of their beneficial effect on overall dental, as well as general health. As dental professionals, it is our prime concern to check this increasing incidence of dental caries and adopt various means to reduce it. [2] The food and beverage industry is increasingly replacing sugar or corn syrup with artificial sweeteners in a range of products traditionally containing sugar. Artificial sweeteners cost the food industry only a fraction of the cost of natural sweeteners in spite of the extremely high profit margins for manufacturers of artificial sweeteners. The US Food and Drug Administration (USFDA) regulate artificial sweeteners Address for correspondence: Vipin Kumar Sharma, Department of Public Health Dentistry, K.D. Dental College and Hospital, Mathura, Uttar Pradesh, India. E-mail: Drvipinsharma2015@gmail.com Received: 24-06-2015 Revised: 01-07-2015 Accepted: 15-03-2016 7

as food additives. Food Additives must be approved by the FDA, which publishes a generally recognized as safe list of additives. [3] In the recent years, the trend toward health, figure and fitness has increased. Energy imbalance between calories consumed on one hand, and calories expended on the other hand, due to urbanization, sedentary lifestyles and excessive consumption of sugary foods along with increased fat consumption, especially saturated fats is leading the Indian population to obesity. Obesity being a primary factor behind type II diabetes is leading India toward becoming a diabetic capital of the world by 2030. So, the growing health awareness today increased the demand for food products that support better health. Consumers are demanding a greater variety of low-calorie products as they strive to make healthier food choices. [4] Low- or reduced-calorie sugar-free foods and beverages are extremely popular in the United States. According to a survey conducted in 2004 by the Calorie Control Council, a trade organization, 180 million adult Americans use these products. Consumers often select these foods and beverages because they want the taste of sweetness without added calories or because they want to reduce the risk of tooth decay. The dietary options that such products provide may be especially helpful in the management of obesity or diabetes mellitus. [5] CLASSIFICATION OF SUGAR SUSBSTITUES [1] Based on sugar substitute being caloric or noncaloric a. Caloric/nutritive sweetener b. Non caloric/ non nutritive sweetener 1. Poly alcohols/sugar alcohols Xylitol Sorbitol 2. Hydrogenated starch hydrolysates Lycasin Palatinit 3. Coupling sugars Sorbose Palatinose Based on their origin 1. Natural sugar substitute 2. Artificial sugar substitute. 1. Cyclamate 2. Saccharin 3. Aspartame 4. Sucralose 5. Neotame Natural sugar substitutes (plant origin) [1] Brazzein Mannitol Miraculin Monatin Monellin Pentadin Sorbitol Stevia Tagatose Xylitol Artificial sugar substitute [1] Acesulfame potassium Alitame Aspartame Cyclamate Dulcin Glucin Glycyrrhizin Glycerol Hydrogenated starch Hydrolysates Inulin Isomalt Lactitol Mabinlin Maltitol Maltoligosaccharide Neohesperidin Dihydrochalcone Neotame Saccharin Sucralose COMPARISON OF SWEETNESS OF VARIOUS SWEETENERS TO THAT OF SUCROSE (SWEETNESS OF SUCROSE = X) [6] 1. Xylitol 1.0x sweetness (by weight), 1.7x sweetness (by food energy), 0.6x energy density 2. Sorbitol 0.6x sweetness (by weight), 0.9x sweetness (by food energy), 0.65x energy density 3. Maltitol 0.9x sweetness (by weight), 1.7x sweetness (by food energy), 0.525x energy density 4. Mannitol 0.5x sweetness (by weight), 1.2x sweetness (by food energy), 0.4x energy density 5. Glycerol 06x sweetness (by weight), 0.55x sweetness (by food energy), 1.075x energy density 6. Monellin 3000x sweetness (by weight) 7. Stevia 250x sweetness (by weight) 8. Thaumatin 2000x sweetness (by weight). Artificial sugar substitutes 1. Acesulfame potassium 200x sweetness (by weight) 2. Aspartame 200x sweetness (by weight) 3. Cyclamate 30x sweetness (by weight) 4. Neotame 8000x sweetness (by weight) 5. Saccharin 300x sweetness (by weight). CALORIC SUGAR SUBSTITUTES Caloric sugar substitutes are group of sweeteners consisting of ingredients that can substitute for both the physical bulk and sweetness of sugar. Products of this type, sometimes called sugar replacers or bulk sweeteners, include the sugar alcohols (also called polyols ) sorbitol, mannitol, xylitol, isomalt, erythritol, 8

lactitol, maltitol, hydrogenated starch hydrolysates, and hydrogenated glucose syrups. [7] Two new sweeteners, trehalose and tagatose, are similar in function to the polyols although they are actually sugars rather than sugar alcohols. Polyols and other bulk sweeteners are used in food products in which the volume and texture of sugar, as well as its sweetness, are important, such as sugar-free candies, cookies, and chewing gum. [8] Many of these products are marketed as diabetic foods. Polyols may also be used in non-food products such as cough drops and throat lozenges. [9] The ADI is defined as the estimated amount (usually expressed in milligrams per kilogram of body weight per day) that a person can safely consume on average every day over a lifetime without risk (ADA 2004). The ADI is usually set at 1/100 of the maximum level at which no adverse effect was observed in animal experiments. [9] Levels of use of food ingredients are set in such a way as to ensure that actual daily intakes do not exceed the ADI. Polyols and other bulk sweeteners have three potential advantages over sugar as food ingredients. First, unlike sugars, they do not promote the development of dental caries. The bacteria in dental plaque, which produce substantial amounts of decay- promoting acid from sugars and starches, produce little or no acid from these substances (USFDA 1996b). A typical claim might be worded as follows: Frequent between meal consumption of foods high in sugars and starches promotes tooth decay. The sugar alcohols in (name of food) do not promote tooth decay. A shorter claim, such as Does not promote tooth decay is permitted on small packages. A 2 nd potential advantage of polyols and functionally similar sweeteners such as tagatose and trehalose is that they produce a lower glycemic response than most sugars and starches do (ADA 2000). Thus, their use may be advantageous for people with diabetes. [9,10] A 3 rd potential advantage is that most polyols are lower in calories than sugar is. Sugar provides 4 Cal/g. However, most of the commonly used polyols provide fewer calories. [10] NON-CALORIC SUGAR SUBSTITUTES These sugar substitutes are also called alternative, artificial, high-intensity, or non-nutritive sweeteners, which can replace the sweetness of sugar while providing few or no calories. In addition to the calorie savings, these sugar substitutes have the advantage of not promoting tooth decay, and they are useful in dietary planning for people who are coping with obesity or diabetes. [11] Sugar substitutes (artificial sweeteners) provide little or no calories or carbohydrates and do not increase blood sugar. Therefore, choosing sugar substitutes can assist with controlling carbohydrate and energy intake. [12] Following are non-caloric sugar substitutes approved by the FDA: Acesulfame K, Aspartame (Nutrasweet/Equal), Neotame, Saccharin (Sweet n Low), Stevia (multiple brands), Sucralose (Splenda). 12 These sugar substitutes offer a sweet taste without increasing blood glucose or calories. Choosing sugar substitutes is one way to assist you with limiting carbohydrate intake. If one chooses to use sugar substitutes or foods and drinks with less sugar, one may have more room to eat a variety of other healthy carbohydrates. [13] Low joule foods and drinks that contain non-nutritive sweeteners (e.g.: soft drinks, cordials, and jellies) can add variety to healthy eating plan without affecting blood glucose levels. Small amounts of nutritive sweeteners will not greatly affect blood glucose levels and can increase food choices. Some diet products containing alternative sweeteners may still be high in saturated fat or salt and are therefore not suitable to include in everyday menu plan e.g.: sugar free (carbohydrate modified) chocolate. Many nutritive sweeteners however, have a laxative effect and can cause diarrhoea if they are eaten in excessive quantities. [14] PUBLIC HEALTH SIGNIFICANCE Polyols are hydrogenated carbohydrates used as sugar replacers. They are non-cariogenic (sugar-free tooth-friendly), low glycemic (potentially helpful in diabetes and cardiovascular disease), low-energy and low insulinemic (potentially helpful in obesity), low-digestible (potentially helpful in the colon), osmotic (colon-hydrating, laxative and purifying) carbohydrates. [15] 9

SUGAR SUBSTITUTES, CHEWING GUM AND DENTAL CARIES Chewing of gum is very much prevalent amongst children, teenagers, and adults. Important defining aspects are the ability to use sugar substitutes in gum manufacture and the prolonged stimulation of a protective flow of saliva. [16] Xylitol and sorbitol are majorly used sugar substitutes in chewing gum. Xylitol in chewing gum is reported to reduce not only the proportions of mutans streptococci in plaque or saliva, but also the amount of plaque present. Xylitol and sorbitol are majorly used sugar substitutes in chewing gum. Xylitol in chewing gum is reported to reduce not only the proportions of mutans streptococci in plaque or saliva, but also the amount of plaque present. [17] It is believed that the benefits of sugar-free gums may be twofold; [18] 1. Increased supersaturation of saliva with the mineral ions, as well as enhanced clearance of sugars from the mouth. 2. Sugar substitution and salivary stimulation could, be equally responsible for the non-cariogenicity of sugar-free chewing gum. PEDIATRIC MEDICINAL SYRUPS The long-term use of sugar-containing medicines has long been considered a cause of dental caries in children. Various studies confirmed that sugarcontaining medicines are an etiological factor in dental caries. [19] However, it was thought by the dental professionals in association with the other authorities and professional bodies to bring a change in sugar containing medicines by replacing sucrose in them by any sugar substitute. [20] Some of the sugar-free medications available are Alex-p (cough syrup), Prospan, Calpol- sugar-free, junior Disprol Suspension, and Benyl in children. The availability of such drugs in India is still poor. [20] FUTURE PROSEPECTIVES OF SUGAR SUBSTITUTES It is now an established fact that sugar definitely contributes to formation of dental cavities. Thus, to prevent dental caries sugar consumption needs to be restricted. However, in view of human taste preference for sweeteners, it is unlikely that many people will voluntarily restrict their sucrose consumption permanently in order to reduce dental caries. Hence, a need arises to replace dietary sugars with substances which provide sweetness but lack the cariogenic effects. For this reason various investigators have searched for alternative sweeteners or sugar substitutes. Sugar substitutes have marked their role in the dental industry also, as they are being frequently used in toothpastes, mouthwashes, mouth fresheners and chewing gums. [21] The use of low-calorie sugar substitutes could improve dietary quality if consumers use calorie savings for the consumption of more nutritious foods. [2] The future trend also includes introducing sugar substitutes in dental floss and toothpicks (xyli-floss and xyli-pick available in some countries). [22] The future prospects are bright for sugar substitutes accounting to the fast pace with which they are replacing natural sugars. However, the use should be within limitation analyzing fully their side-effects. [23] CONCLUSION There is a considerable amount of information on the effect of non-sugar sweeteners on dental health. This comes from various types of studies like incubation experiments, plaque ph studies, enamel scab experiments, animal studies, and human clinical trials. Xylitol has been subjected to many studies of different types and can be classified as non-cariogenic. There is evidence that xylitol has a positive anti-cariogenic effect within dental plaque, but it is premature to label it anti-cariogenic other than its action as a non-cariogenic salivary stimulant, thus encouraging remineralization of incipient carious lesions. The evidence for casual relationship between sugars and dental caries has been established. Dental caries still remains a very costly and widespread disease that in many industrialized countries affects mainly disadvantaged individuals and is of serious concern in many developing countries. RECOMMENDATIONS Dental research workers should be encouraged to investigate the properties of newer non-sugar sweeteners so that, if they have favorable dental properties, their approval may be quickened and their use encouraged. Chewing gum containing protective substance 10

is effective and has the potential to significantly improve oral health status. Policy makers should consider the public health benefits of chewing gum containing dental protective substances especially xylitol. The consumers need to be aware of the polyols and similar substances used as bulk sugar substitutes in the food products so that they can limit their intake sufficiently to avoid any health discomforts. The availability of a variety of safe sugar substitutes could be benefit to consumers as it enables food manufacturers to formulate a variety of good testing sweet foods and beverages that are safe for the teeth and lower in caloric content than sugar-sweetened foods and beverages. REFERENCES 1. Yadav P, Kaur B, Srivastava R, Srivastava S. Sugar substitute and health. J Dent Med Sci 2014;13:68-75. 2. Tandel KR. Sugar substitutes: Health controversy over perceived benefits. AACN Clin Issues Crit Care Nurs 1998;16:42-9. 3. Kroger M, Meister K, Kava R. Low calories sweeteners & other sugar substitutes: A review of the safety issues. J Indin Dent Assoc 2006;5:24-5. 4. Weihrauch MR, Diehl V. Artificial sweeteners Do they bear a carcinogenic risk? Ann Oncol 2004;15:1460-5. 5. Virginia M. How Sweet it is. AANNTJ 2005;3:15-7. 6. Harris NO, Garcia Godoy F. Primary Preventive Dentistry Sugar Substitutes. 6 th ed. New Jersey: Prentice Hall Health; p. 395-6. 7. Whitehouse CR, Boullata J, McCauley LA. The potential toxicity of artificial sweeteners. AAOHN J 2008;56:251-9. 8. Donnell KO, Kearsley MW. Sweeteners and sugar alternative in food technology. ABNF J 2009;2:34-48. 9. Bernt WO. Erythitol: A review of biological and toxicological study regulatory toxicology and pharmacology. Br J Nutr 1996;24:1-197. 10. Hammnd KK. Qualitative and quantitative determination of artificial sweetener saccharin sodium by FTIR spectroscopy. IAPBC J 2014;3:65-72. 11. Ranjan R, Jaiswal J, Jeena J. Stevia as a natural sweetener. Int J Res Pharm Chem 2011;1:21-9. 12. Frostell G, Keyes PH, Larson RH. Effect of various sugars and sugar substitutes on dental caries in hamsters and rats. J Nutr 1967;93:65-76. 13. Scheinin A, Bánóczy J. Xylitol and caries: the collaborative WHO oral disease preventive programme in Hungary. Int Dent J 1985;35:50-7. 14. Edgar WM. Sugar substitutes, chewing gum and dental caries A review. Br Dent J 1998;184:29-32. 15. Peter L, Anna H, Ingegerd M, Svante T. Effect of various mouth-rinses on caries reduction. Acta Odontol Scand 2003;61:21-9. 16. Bowen WH. The effects of sucralose, xylitol, sorbitol on remineralisation of caries lesions in rats. J Nutr 1992;71:1166-8. 17. Beiswanger BB, Boneta AE, Mau MS, Katz BP, Proskin HM, Stookey GK. The effect of chewing sugar-free gum after meals on clinical caries incidence. J Am Dent Assoc 1998;129:1623-6. 18. Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc 2000;131:909-16. 19. Alanen P, Holsti ML, Pienihäkkinen K. Sealants and xylitol chewing gum are equal in caries prevention. Acta Odontol Scand 2000;58:279-84. 20. Tanzer JM. Xylitol chewing gum and dental caries. Int Dent J 1985;35:58-65. 21. Mäkinen KK, Mäkinen PL, Pape HR Jr, Peldyak J, Hujoel P, Isotupa KP, et al. Conclusion and review of the michigan xylitol programme (1986-1995) for the prevention of dental caries. Int Dent J 1996;46:22-34. 22. Machiulskiene V, Nyvad B, Baelum V. Caries preventive effect of sugar-substituted chewing gum. Community Dent Oral Epidemiol 2001;29:278-88. 23. Addy M, Perriam E, Sterry A. Effects of sugared and sugar-free chewing gum on the accumulation of plaque and debris on the teeth. J Clin Periodontol 1982;9:346-54. How to cite the article: Sharma VK, Ingle NA, Kaur N, Yadav P, Ingle E, Charania Z. Sugar substitutes and health: A review. J Adv Oral Res 2016;7(2):7-11. Source of Support: Nil. Conflict of Interest: None declared. 11